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cists, or health policy analysts about whether, first, fairness or equity requires some priority be given to the sickest or worst-off and, second, if so, how much and in what circumstances. Although this controversy has prevented the committee from attempting to incorporate any such priority into our analytic model, it is no reason for policymakers to ignore the issue in setting priorities for vaccine development or, for that matter, for health care allocation and investment more generally. That is why the committee has flagged, briefly discussed, and given examples of the issues that arise specifically in the prioritization of potential vaccines.

Fair Chances Versus Best Outcomes

The final issue of justice or fairness in the distribution of health benefits to which the committee calls attention here has been characterized as the conflict between fair chances and best outcomes. The conflict is most pressing when the health care intervention is life-saving, and not all whose lives are threatened can be saved, although it arises when the threat is to health and function as well. The issue has received the most attention in the context of organ transplantation where there is a scarcity of life-saving organs such as hearts and lungs, resulting in many deaths each year of patients waiting for an organ for transplant. An abstract example in the area of transplantation illustrates the problem. Suppose two patients are each in need of a heart transplant to prevent imminent death, but only one heart is available for transplant. Patient A has a life expectancy with a transplant of 10 years and patient B has a life expectancy with a transplant of 9 years, with no difference in their expected quality of life. (Of course, precise estimates of this sort are typically not possible, but the point is that there is a small difference in the expected benefits to be gained depending on which patient gets the scarce organ).

Once again, if the we wish to use scarce resources to maximize health benefits or QALYs, then we should straightaway prefer patient A. But patient B might argue that it is unfair to give her no chance to receive the scarce heart. Just like A, she needs the heart for life itself and will lose everything—that is, her life—if she does not receive it. It is unfair, B charges, to give the organ to A because of the small difference in expected benefits from doing so; that difference is too small to justly determine who lives and who dies. Instead, each should receive a fair chance of getting the organ, which might in this case be either an equal chance through a random selection between A and B, or a weighted lottery that gives the patient who would benefit more some greater likelihood of being selected to receive the organ. Like the other two considerations of justice just discussed, this too is far more complex and controversial than the committee can pursue here, but it is another example of when society might reasonably choose to constrain resource allocation aimed at maximizing health benefits in order to be fair to the individuals who will be affected by the resource allocation.



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